Section 1: Your details

Your name *

Your role *

You must have a Registration Authority role to request a new CIS domain.

Your email address *

Name of the organisation you work for *

Organisation type *

For example, pharmacy, hospice, GP practice.

ODS code of the organisation you work for *

Look up your ODS code: https://odsportal.digital.nhs.uk/Organisation/Search

Name of the organisation you are requesting this domain for *

ODS code of the organisation you are requesting this domain for *

Look up ODS code: https://odsportal.digital.nhs.uk/Organisation/Search

Section 2: Details of request

Email domain(s) to be added (must start with @). You can enter more than one domain. *

Reason for access to national records. Provide this for each email domain requested. *

When are new members of staff given their email addresses? Provide number of days or weeks after they join. Provide this for each email domain requested. *

What employment checks are completed? Provide this for each email domain requested. *

Are all employment checks completed before new members of staff are given the email address(es) you have included in this form? *

• Yes
• No

As the requestor, are you assured that there is a robust process to bind an identity or individual to the organisation's email domain(s)? *

• Yes
• No

Additional notes

Please provide any other information you feel will be useful to support your request